Healthcare Provider Details

I. General information

NPI: 1629034103
Provider Name (Legal Business Name): JILLY KUNJUNNY VIDYASAGARAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 11/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4024 BROOKHAVEN AVE
PASADENA TX
77504-1902
US

IV. Provider business mailing address

4024 BROOKHAVEN AVE
PASADENA TX
77504-1902
US

V. Phone/Fax

Practice location:
  • Phone: 713-944-2324
  • Fax: 713-944-1539
Mailing address:
  • Phone: 713-944-2324
  • Fax: 713-944-1539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberJ2829
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: